Provider Demographics
NPI:1902207053
Name:SIMONIAN, MAIRA (BA)
Entity Type:Individual
Prefix:
First Name:MAIRA
Middle Name:
Last Name:SIMONIAN
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 E 15TH ST
Mailing Address - Street 2:
Mailing Address - City:MERCED
Mailing Address - State:CA
Mailing Address - Zip Code:95341-6217
Mailing Address - Country:US
Mailing Address - Phone:209-381-6879
Mailing Address - Fax:209-725-3775
Practice Address - Street 1:300 E 15TH ST
Practice Address - Street 2:
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95341-6217
Practice Address - Country:US
Practice Address - Phone:209-381-6879
Practice Address - Fax:209-725-3775
Is Sole Proprietor?:No
Enumeration Date:2014-09-09
Last Update Date:2014-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1013030808Medicaid